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On-line version ISSN 2223-6279
Print version ISSN 0379-8577

Curationis vol.41 n.1 Pretoria  2018 



Barriers to tuberculosis and human immunodeficiency virus treatment guidelines adherence among nurses initiating and managing anti-retroviral therapy in KwaZulu-Natal and North West provinces



Lufuno MakhadoI; Mashudu Davhana-MaseleseleI; Jason E. FarleyII

ISchool of Nursing Science, North-West University, South Africa
IISchool of Nursing, Johns Hopkins University, United States





BACKGROUND: Nurses, as front-line care providers in the South Africa's health care system, are called upon to deliver integrated interventions for tuberculosis and human immunodeficiency virus (TB and HIV) including nurse-initiated management of anti-retroviral therapy (NIMART) and anti-TB treatment. Adherence to treatment guidelines and factors associated with non-adherence to treatment guidelines among nurses remain under explored.
PURPOSE: To explore and describe barriers to treatment guidelines adherence among nurses initiating and managing anti-retroviral therapy and anti-TB treatment in KwaZulu-Natal and North West provinces.
DESIGN: This study employed a qualitative exploratory descriptive design.
METHODS: Four semi-structured focus group interviews were conducted during 2014 each consisting of four to eight NIMART trained nurses. Audiotaped interviews were transcribed verbatim and analysed using Atlas T.I. software.
FINDINGS: During data analysis, two themes emerged: (1) NIMART trained nurses' distress about TB and HIV guidelines adherence that is inclusive of lack of agreement with guidelines, poor motivation to implement guidelines, poor clinical support and supervision, resistance to change, insufficient knowledge or lack of awareness and (2) exterior factors inhibiting nurses' adherence to treatment guidelines which incorporated organisational factors, guidelines-related factors and patient-related factors.
CONCLUSION: This qualitative study identified that nurses have substantial concerns over guideline adherence. If NIMART trained nurses' barriers inhibiting adherence to treatment guidelines cannot be remedied, patient outcomes may suffer and South Africa will struggle to meet the 90-90-90 targets.




Adherence to treatment guidelines seems to be a major challenge among nurses caring for people living with human immunodeficiency virus (PLWH) and tuberculosis (TB) patients. Guidelines adherence is also associated with improvement of patient outcomes. Unfortunately, adherence to TB and human immunodeficiency virus (HIV) guidelines among health care providers varies based on services provided as well as with individual perspectives around the stipulated recommendations (Hiransuthikul et al. 2005; Low & Eng 2009; Naidoo et al. 2010; Peterson et al. 2011; Saraceni et al. 2011). The nursing profession, in general, has demonstrated excellent guideline-based care delivery before diagnosis, with initiation of anti-retroviral therapy (ART), as well as patient monitoring (Hiransuthikul et al. 2005; Low & Eng 2009; Naidoo et al. 2010; Peterson et al. 2011; Saraceni et al. 2011). Adherence to treatment guidelines, however, is influenced by many factors, including health care providers' familiarity with or agreement with guidelines (Crocker et al. 2013) in addition to the time-pressured environment of primary care (Crocker et al. 2013).

Six factors have been consistently reported to influence adherence to treatment guidelines: familiarity, awareness, outcome expectancy, self-efficacy, motivation and agreement (Cabana et al. 1999; Satman et al. 2010; Vashitz et al. 2011). The influence of each of these factors differs by profession (physicians vs. nurses vs. dieticians, for example), educational background, care experience and personality (Satman et al. 2010; Vashitz et al. 2011). Lack of agreement with treatment guidelines, poor outcome expectancy and paucity of evidence supporting the recommendations had been found to be stronger barriers to physicians, whereas practical concerns, such as expertise, workload and patient comfort, were deemed to be more important for nurses (Cabana et al. 1999; Satman et al. 2010; Vashitz et al. 2011).

Nurses as the front-line providers in South Africa's health care system are essential to integrated interventions for TB/HIV. Factors inhibiting nurse-initiated management of anti-retroviral therapy (NIMART) nurses' adherence to treatment guidelines in South Africa remain under explored. It is of paramount importance to investigate the relationship between provider adherence to clinical guidelines and its influence towards quality care provision. This study sought to explore and describe barriers to treatment guidelines adherence among nurses initiating and managing ART and anti-TB treatment in Kwazulu-Natal (KZN) and North West (NW) provinces.



A qualitative, exploratory descriptive design was used to explore and describe barriers to treatment guidelines adherence among nurses initiating and managing ART and anti-TB treatment in KZN and NW provinces.

Context of the study

The study was conducted in two districts within two provinces, Ugu district (Kwazulu-Natal Province) and Ngaka Modiri Molema district (North West Province), of South Africa.

Sampling criteria

Nurse-initiated management of ART-trained nurses initiating and managing ART and anti-TB treatment were sampled using purposive sampling and recruited from the primary health care (PHC) and community health centres (CHC) in KZN and NW provinces which were sampled using systematic random sampling. Sixteen facilities (eight CHCs and eight PHCs) were selected from KZN and NW provinces. Nurses were purposively selected if they were NIMART trained, currently initiating and managing ART for at least 12 months in a CHC or PHC and accredited to provide ART services. The study sample consisted of 24 participants consisting of 4-8 NIMART trained nurses who agreed and consented to participate in the study. All participants were NIMART trained nurses, of whom 17 were female (70.8%). Other demographic features are presented in Table 1.



Data collection

Data were collected from February to April 2014. Each interview was initiated with the central question 'what are the barriers to treatment guidelines adherence among NIMART trained nurses'. The central question was discussed in all sessions followed up by probing and follow-up questions in relation to adherence to treatment guidelines. The time of day was selected by the participants prior to the focus group sessions. The focus group interview sessions were carried out in a quiet room at one of the hospitals in Port Shepstone and at North-West University School of Nursing Sciences boardroom, which lasted 90-140 min. All focus group discussions (FGD) were recorded using a digital recorder and were transcribed verbatim for later analysis. Data saturation was reached within the fourth session as no other new information arose from the FGD from both districts.

Data analysis

Transcripts were compared with audiotapes and field notes to confirm the correctness of the transcribed data. Demographic characteristics were analysed from the focus group demographic data sheet. This study used ATLAS T.I. software program (version 7.0) and followed the basic steps of notice-collect-think (NCT) analysis (Friese 2012). These basic steps enabled the researcher to work in a systematic manner instead of declaring the software to be the method itself (Friese 2012). The researcher started by noticing aspects of the data that led to an idea for a label and began to collect what was noticed in the form of codes (Friese 2012). This involved the following steps: familiarisation with raw data; identifying an index of all the codes and categories to be used from the raw data; applying the index to all the raw data by noting transcripts with the codes; charting all the raw data from the same code in a particular document; and interpreting themes from the charts in relations to the range and strength of opinions, as well as any associations or relationships between themes (Friese 2012). Quotations from these interviews are used in this article to illustrate vital points which had been controlled using available literature.

Measures to ensure trustworthiness

In order to provide trustworthiness of the qualitative analysis, the researcher followed Guba's (1981) criteria of ensuring credibility, transferability, dependability and confirmability. Credibility (internal validity) was addressed by having two researchers independently reading and coding the transcribed focus group sessions. Transferability (external validity and generalisability) was enforced by providing rich, thick description (Lincoln & Guba 1985) and sharing the results with content experts and conducting further literature review. Confirmability (objectivity) was assessed by comparing the transcribed focus group sessions with the extensive notes taken by the non-participating note-taker from the focus group. Dependability (reliability) was achieved by triangulation of methods which involved the use of FGD, field notes and observations (Lincoln & Guba 1985).

Ethical considerations

Ethical clearance for the study was given by the North-West University ethics committee (NWU-000033-13-A9). Provincial Department of Health for NW and KZN granted permission to conduct the study. Voluntary participation and written consent of all participants was sought, and detailed information about the research was provided.


Results and discussion

Four focus group interview sessions were conducted consisting of 4-8 NIMART trained nurses in each group, two sessions in each province. In the process of empowering nurses in the initiation and management of ART in South Africa, usage and adherence to treatment guidelines seem to be hindered by multifaceted factors. Nurse-initiated management of ART-trained nurses expressed barriers that were inhibiting them from fully adhering to treatment guidelines in their facilities and throughout their caregiving role. Analysis of the interview data exposed two major themes: (1) NIMART trained nurses' negative distress about TB/HIV guidelines and (2) exterior factors inhibiting NIMART trained nurses' adherence to treatment guidelines. These themes and associated subthemes are described in Table 2.



Theme 1: Nurse-initiated management of anti-retroviral therapy-trained nurses' distress about tuberculosis/human immunodeficiency virus guidelines adherence

In this study, 'distress' refers to the way in which nurses feel, worry and are concerned about using and adhering to the TB/HIV treatment guidelines. The following barriers were identified as leading to their distress, namely lack of agreement with guidelines, poor motivation to implement guidelines, poor clinical support and supervision, resistance to change and insufficient knowledge or lack of awareness.

Lack of agreement with the guidelines

The NIMART trained nurses verbalised that the guidelines were not user friendly, indicating the issue of the complexity of the treatment guidelines and stating that they find it hard to work with the TB and HIV guidelines. TB, HIV and Practical Approach to Lung Health and HIV/AIDS in South Africa (PALSA) Plus guidelines were also said to contradict one other. The NIMART trained nurses expressed that:

'It is not easy to use the guidelines that you don't understand and again the guidelines have other things that are confusing to me and no one seems to have answers to my queries as well.' (P9S4, male, 44 years old)


'The guidelines are contradictory, and we (are) dealing with integrated services (TB and HIV) so the TB guideline says this and the HIV or ART guideline says that whereas the PALSA Plus [another type of clinical guide] is saying this on the other side.' (P9S4, male, 44 years old)

Furthermore, NIMART trained nurses also felt that they are not involved in the development of guidelines, or consulted for review and, as a result, they are required to implement the guidelines recommendations as they are regardless of whether they agree or not. Nurse-initiated management of ART-trained nurses highlighted that:

'I have a problem with the guidelines because I was not involved in the development of it, I don't know about you nurses but I do have a problem. We are not engaged in the development but are fully expected to implement it whether we agree or not. And In addition, we don't even get to be consulted before hand if the guideline is suitable for use or not. It's an obligation and it's not easy to adhere to something you do not agree to.' (P12S4, male, 42 years old)

The use of treatment guidelines is discouraged when the NIMART trained nurses perceives it to be unusable in daily practice (Abrahamson, Fox & Doebbeling 2012). Other evidence pointed out that nurses felt the treatment guidelines were too complicated and criticised the treatment guidelines as too 'cook book, too time consuming and too cumbersome' (Afreen & Rahman 2014; Christakis & Rivara 1998). However, NIMART trained nurses would be in a better position to follow guidelines that have been developed with nursing input and this may result in a greater sense of ownership. This notion is supported by a study indicating that treatment guideline adherence was high among Dutch general practitioners (GPs) because the guideline was developed by their fellow GPs (Lugtenberg et al. 2011).

Poor motivation, support and supervision of nurse-initiated management of anti-retroviral therapy-trained nurses

Lack of support from the managers and programme coordinators was reported to affect NIMART trained nurses' adherence to treatment guidelines. Nurse-initiated management of ART-trained nurses revealed that:

'The [TB & HIV] programme managers took long to come back to us, they don't even visit for support unless there is some provincial visit, that's when they will come and you will find that all the wrongs would have been made right earlier if they took support visits seriously and we wouldn't have been stuck with the old guidelines or protocols that we using even now.' (P7S4, female, 46 years old)


'We are not supported or motivated to use the guidelines. We do have programme coordinators, managers and supervisors but they are not supportive or encouraging to us.' (P5S3, female, 58 years old)

It was evident that NIMART trained nurses feel that the importance of support for treatment guideline use is somewhat ignored and it makes clinical and monitoring and evaluation visits impossible as it was felt that the programme managers and physician mentors do not see the need to provide routine support. Abrahamson et al. (2012) further emphasised that nurses acknowledge the importance of receiving support from physicians in terms of treatment guideline use and this was found lacking in their facilities. In addition, the lack of support further discourages the spirit of cooperation.

Adherence to treatment guidelines was said to be discouraged by the absence of cooperation among health care providers. Nurse-initiated management of ART-trained nurses are not the only health care providers that patients come across and it takes the whole multidisciplinary team to adhere to the treatment guidelines and record everything in the patient files. One NIMART trained nurse articulated that:

'Most of the trained nurses do not give feedback to other colleagues hence a problem of owning a programme. Nurses need to know that it is not their programme, we work together trained or not trained for one reason only that is provision of quality care and treatment to our patients.' (P10S2, male, 34 years old)

Another participant emphasised that:

'We would love to [sic] for our doctors to attend these workshops because you find that our doctors are not, they don't know any guidelines. It even amazes me in ART some doctors don't know anything that needs to happen during initiation and as a nurse you will be referring clients and you will be afraid to tell the doctor to say please do one, two, three and this as it will be like you are undermining or what so ever.' (P4S3, male, 27 years old)


'Some of the challenges that we face are due to lack of teamwork between enrolled nurses, doctors, ENAs [Enrolled Nursing Auxiliary] and us as professional nurses, there is no communication between this categories. And we are supposed to work hand in glove with one another for the provision of quality care to our patients.' (P7S4, female, 46 years old)

This is a major challenge leading to poor cooperation between health care providers. The use of guidelines is discouraged when there is no lateral cooperation between health care workers (Abrahamson et al. 2012; Lugtenberg et al. 2009). It was further emphasised that communication gap is a reason for non-adherence to treatment guidelines and use (Afreen & Rahman 2014). Likewise, nurses work closely with doctors; however, this relationship has had a long history of conflict and often it is stereotyped as 'us versus them', that is, nurses versus doctors and vice versa (Lugtenberg et al. 2009). This had been regarded as a very unhealthy approach to teamwork, proper communication and health relationship (Lugtenberg et al. 2009).

Resistance to change

Nurse-initiated management of ART-trained nurses expressed that they experience difficulty in coping with the amount of change in the health care system and they find it hard to move from previous ways of doing things as treatment guidelines keep changing and this is because change is difficult for them. One NIMART trained nurse stated that:

'I think it is very difficult to change, it is very hard to move from the previous practice and the way we use to do things to this NIMART and TB/HIV integrated services. So I think change is a huge problem that needs attention.' (P9S4, male, 44 years old)

These statements are in line with available literature revealing that health care providers feel that they are not sufficiently motivated to change and that it is hard for them to overcome inertia of what they used to practise versus what they are expected to implement and this is because of habits and routines rooted to them in accordance with previous guidelines (Lugtenberg et al. 2009, 2011). Hence, they felt that this needs to be attended to in order to assist them to cope with the challenges they face and to be motivated efficiently in their care giving role.

Insufficient knowledge and lack of awareness

It is of paramount importance that all NIMART trained and untrained nurses receive the necessary orientation as to make them aware of the available treatment guidelines as well as provision of follow-up or in-service training. Most NIMART trained nurses verbalised that they lack necessary education and training needed to keep them updated with the NIMART program and anti-TB treatment to TB and HIV patients. The nurses had this to say about education and training:

'Lack of training within the facilities is a major challenge in my opinion. Like for instance there is only one NIMART trained nurse in my facility, 'me' and what happens like now when I am not there in the facility?' (P8S2, female, 41 years old)

Another participant added that:

'Indeed it is a problem and puts a lot of pressure to us as NIMART trained nurses as majority of other nurses are not NIMART trained and it also boils back to the patient and this reduces the adherence to the guidelines as I don't own the patient.' (P10S2, male, 34 years old)

Another NIMART trained nurse emphasised that: